Commentary from the Editor in Chief Emeritus
by Forest Tennant, MD
 Recently, as described
previously, the State of Washington issued regulations restricting the amount of opioids a
generalist physician can prescribe to a patient. These regulations don’t apply to
“pain specialists.”
We view this development with considerable regret and uncertainty. We also have many
questions that we believe the State of Washington must publicly provide lest the rest of
the nation believe that Washington will now lead the country in both personal computer
software and the under-treatment of suffering pain patients.
Here are some of our questions.
1. Washington states that this restriction is due to the increase in deaths from
oxycodone and methadone. Does the state of Washington have specific data showing that this
has occurred there?
2. Does Washington have data showing that the overdosed medication was prescribed by
generalist doctors and not purchased from Canada, on the web, or on the streets?
3. How do they define “pain specialists”? Hopefully, it’s not Board
Certification from the American Academy of Pain Medicine since a recent survey published
by this organization showed that only about 30% of their practitioners prescribe Schedule
II opioids.
4. Does Washington have a plan for handling those citizens who must now leave their
State to obtain adequate treatment in other states?
If Washington indeed does have answers to these questions, and there has been an
increase in the opioid deaths from opioids prescribed by generalists in this state, we
will probably conclude that their new regulation is a necessity.
PPM has long admonished doctors to follow the National Medical Board Guidelines for pain
treatment. We have called for special intractable pain practices to deal with the severe
pain patient who may need double or triple opioid therapy. For the past several issues, we
have featured at least one article on the great advantages of body fluid testing in
preventing diversion and deaths. We have sponsored a national blood level study of opioids
to encourage physicians to use this in high dose cases to document tolerance, compliance,
and necessity for a high dose. And, most recently, we have editorialized that generalist
physicians, nurse practitioners, and physician assistants shouldn’t prescribe
Schedule II or high dosages of opioids unless they structure their practices to treat pain
patients with the extra time and monitoring that a pain patient requires above and beyond
the usual general medical patient.
Our recent editorial about generalist physicians and the prescribing of potent opioids
appears to have the same aegis as the State of Washington regulations. We are aware that
many States that have the greatest increase in methadone and oxycodone deaths were those
in which generalist MD’s and poorly supervised PA’s and NP’s practice.
Despite our great concern, we seriously wonder if Washington’s dosage restrictions
are in the best interest of all concerned parties. Washington is a large state with many
rural villages and towns without “pain specialists.” Are we now to assume that
the soldier in pain returning from Iraq, the lumberjack with collapsed vertebrae, or the
young mother with fibromyalgia must now lay in a home-bed and suffer? It seems to us the
great State of Washington has a lot of soul-searching to do and a lot of answers to
provide.
— June 2007
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